LABORATORY TESTS REQUIRED TO REACH THE DIAGNOSIS IN PATIENTS WITH GROSSLY ELEVATED ESR

This study was done in medicine indoor department of Rajshahi Medical College Hospital from January 2004 to March 2004. Consecutive 100 patients, who were found to have an ESR equal to or more than 100 mm in 1st hour, were included in this study. Among them 56 were male and 44 were female. All of them were classified in five age groups. Haematological disorder appeared to be the most common cause (41%) of marked ESR elevation; followed by infectious diseases (36%) and connective tissue disorders (17%). In 4% cases the cause can not be elicited. In this study, most commonly done investigation was peripheral blood film (76 patients) and gave positive clue to diagnosis in 45% cases. Bone marrow study was done in 53 cases and gave positive diagnosis in 69% cases. Other tests with high diagnostic yield were RA test (35%), X-ray spine (62%), Widal test (42%), Splenic aspirate study for kala-azar (46%), DAT for kala-azar (47%), FNAC of lymph node (77%), Pleural fluid study (100%). Most of the patients have needed 3 (46% patient) to 4 (27% patient) special investigations along with routine investigations to reach the diagnosis. 1. Assistant Professor, Department of Medicine, Rajshahi Medical College, Rajshahi 2. Assistant Professor, Department of Medicine, , Dhaka Medical College, Dhaka 3. Registrar, Nephrology Unit, Dhaka Medical College, Dhaka 4. Professor & Head, Department of Medicine, Sir Salimullah Medical College, Dhaka Correspondence : Dr. Md. Zahirul Haque, Assistant Professor, Department of Medicine, Rajshahi Medical College, Rajshahi elevated erythrocyte sedimentation rate. This study is carried out in Rajshahi Medical College Hospital to find out the common aetiologies of grossly elevated ESR and to list the minimum laboratory investigations to find out the cause. Materials and Methods: This was a prospective study which was carried out in medical indoor of Rajshahi Medical College Hospital from January 2004 to March 2004. Consecutive 100 patients, who were advised to test the ESR by their physicians for their complaints and found to have an ESR, equal to or more than 100 mm in 1st hour, were included in this study. Out of 100 patients 56 were male and 44 were female. Patients were divided into five age groups having age range of less than 20 years, 20 to 30 years, 30 to 45 years, 45 to 65 years and more than 65 years respectively. The Westergren method of determining the ESR was used without correction for the haemoglobin value. Detailed history, thorough clinical examinations were performed to elicit the cause. Total and differential J MEDICINE 2009; 10 : 7-11

elevated erythrocyte sedimentation rate.This study is carried out in Rajshahi Medical College Hospital to find out the common aetiologies of grossly elevated ESR and to list the minimum laboratory investigations to find out the cause.

Materials and Methods:
This was a prospective study which was carried out in medical indoor of Rajshahi Medical College Hospital from January 2004 to March 2004.Consecutive 100 patients, who were advised to test the ESR by their physicians for their complaints and found to have an ESR, equal to or more than 100 mm in 1 st hour, were included in this study.Out of 100 patients 56 were male and 44 were female.Patients were divided into five age groups having age range of less than 20 years, 20 to 30 years, 30 to 45 years, 45 to 65 years and more than 65 years respectively.The Westergren method of determining the ESR was used without correction for the haemoglobin value.
Detailed history, thorough clinical examinations were performed to elicit the cause.Total and differential count of WBC, Haemoglobin percentage, Urine R/M/ E and X-ray chest P/A view were done in all cases.Special investigations like Comment on peripheral blood film, Bone marrow study, Splenic aspirate study for LD bodies, Widal test, Tuberculin test, Ultrasonography, X-ray skull and dorso-lumber spine, Lymph node biopsy, FNAC, ANF, RA test, Pleural, Ascitic and Cerebrospinal fluid study were done in special cases.
All patients were analyzed with male-female distinction along with age group distribution, socioeconomic condition, occupation, clinical presentation and possible diagnosis by using other investigations.The data were analyzed by SPSS version 10.

Sex Number
Male 56 Female 44 Majority of the male patients (27%) were within 31 -45 age group and most of the female patients (36%) were within 21 -30 age group (Tabel-II).Grossly elevated ESR (>100 mm in 1 st hour) is a common finding all over the world.There are numerous aetiologies of marked ESR elevation.All the aetiologies in our country may not be as same as in other part of the world; there should be some variation.This study was conducted on 100 cases with ESR equal to or more than 100 mm in 1 st hour selected from the medicine department of one of the medical college hospital in northern Bangladesh.
In the present study, majority of the patients were male (56%).No other study is available regarding the male: female ratio among the patients with grossly elevated ESR.However, this may be due to the fact that male patients present themselves in hospitals more commonly than female.General attitude of our female toward hospital admission which they tend to avoid may be another reason.
In this series, majority of the male patients (27%) were within 31 -45 age group and most of the female patients (36%) were within 21 -30 age group (Table-II).One of the common cause of marked ESR elevation is connective tissue diseases, which are most prevalent in the young female patients.This may be cause of higher percentage of female patients of younger age group.
In this study, Haematological disorder appears to be the most common cause (41%) of marked ESR elevation; followed by infectious diseases (36%) and connective tissue disorders (17%).In 2% cases the cause is chronic liver disease.In 4% cases the cause can not be elicited.Among the all patients 30% cases A study done by Fincher RM & Page MI (1986) 6 also revealed the most common cause of markedly raised ESR was infection (33%) with malignant and renal disease each responsible for 17% and inflammatory disorder for 14%.In 10% no cause was identified.

Test
It is surprising not to see the infectious disease as the commonest diagnosis in patients with markedly elevated ESR in this study.Infectious disease is more prevalent in a developing country like Bangladesh, and kala-azar, one of the known causes of marked ESR elevation, is endemic in this region.One possible explanation of this result may be the site of this study which was done in medicine unit of Rajshahi Medical College Hospital.It is a tertiary level referral hospital.Most of infections can be diagnosed and treated at primary and secondary level, such as, at union, upazila or district level.Only those with complications or with diagnostic dilemma are being referred to this hospital.This may also be the possible explanation why haematological disorders are the most prevalent diagnosis among these patients.Haematological diseases are difficult to diagnose and treat in the upazila and the district level and most of them are referred to this tertiary referral hospital.Moreover, Haemopoitic malignancy cases getting repeatedly admitted for blood transfusion or therapy might have significantly increased their number in this study thereby making infectious diseases as second common cause of marked elevation of ESR.
Renal disorder was found to be an important cause of markedly raised ESR in most of the studies.But here, we do not get any of them.Probably this is due to the separate nephrology unit in Rajshahi Medical College Hospital where all the renal patients are admitted.
Connective tissue diseases are responsible for 17% cases in this study.This is comparable to the Zimbabwean study (17%) but reasonably less than some of the European and American studies 7 where infectious diseases are less common and percentage of connective diseases is higher.
No cause was found in the 4% of patients in this study.This is less than other studies where it varied from 5% 8 to 10% Though this is a tertiary-hospital study which may not truly reflect the community, all level of practitioners must be aware of this hospital picture.This study may help them in approaching their patients with markedly elevated ESR in a cost effective way, thereby reducing the cost as well as suffering of poor patients of this country.

Table-II Age Distribution of the patients
6.The rate of positive diagnosis is high in our study.This is possibly due to this study which has been done on symptomatic patients admitted in the hospital.Most other studies included both symptomatic and asymptomatic patients.Simple, non-invasive, widely available laboratory tests may yield the diagnosis in majority of the cases with high elevation of ESR.We can avoid costly, sophisticated investigations if we give emphasis on careful history taking and meticulous physical examination.